Summary: The Council was at fault in delaying the review of Ms X’s Care and Support Plan and in assessing her for, and arranging, adaptations to her bathroom. The Council did not unfairly restrict her access to its services. The Council should agree to apologise to Ms X and make her symbolic payments to acknowledge the injustice caused.

The complaint

1. Ms X complained that the Council:
1. Delayed in carrying out a review of her care and support plan (CSP) which caused her distress at a time when she was unwell;
2. Unfairly restricted her contact with the Council so she had to go through a social worker to access any council service;
3. Delayed in carrying out adaptations to her bathroom, partly because she was restricted from making direct contact with the relevant officers; and
4. Failed to respond to her complaint of May 2025.
2. Ms X says the Council’s actions caused her distress, frustration, uncertainty and time and trouble.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(1), as amended)

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How I considered this complaint

5. I considered evidence provided by Ms X and the Council as well as relevant law, policy and guidance. I discussed Ms X’s complaint with her on the telephone.
6. Ms X and the Council had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Legislation, policy and guidance

Care Act Assessment (CAA)

7. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
8. Councils must carry out assessments over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs. Councils should tell people when their assessment will take place and keep them informed throughout the assessment.

Care and Support Plan (CSP)

9. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan (or a support plan for a carer). The care and support plan should consider what needs the person has, what they want to achieve, what they can do by themselves or with existing support and what care and support may be available in the local area. When preparing a care and support plan the council must involve any carer the adult has. The support plan must include a personal budget, which is the money the council has worked out it will cost to arrange the necessary care and support for that person.

Reviews

10. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Government Care and Support Statutory Guidance says councils should review plans at least every 12 months. Councils should consider a light touch review six to eight weeks after agreeing and signing off the plan and personal budget. They should carry out reviews as quickly as is reasonably practicable in a timely manner proportionate to the needs to be met. Councils must also conduct a review if an adult or a person acting on the adult’s behalf makes a reasonable request for one.

Direct payments

11. Direct payments are monetary payments made to individuals who ask for them to meet some or all of their eligible care and support needs. They enable people to arrange their own care and support to meet those needs. The council must ensure people have relevant and timely information about direct payments so they can decide whether to request them. If they do so, the council should support them to use and manage the payment properly.

The Council’s Unreasonable Behaviour Policy

12. To fulfil its statutory duty of care to its workforce, the Council has an Unreasonable [customer] Behaviour Policy.
13. The policy says that the precise nature of the action to be taken in relation to an unreasonable individual should be appropriate and proportionate to the nature and frequency of their contacts with the Council at that time. Restrictions may include restricting contact to an individual named officer or team.
14. A decision on whether or not the policy will be applied to an individual displaying unreasonable behaviour should be taken at Assistant Director level or above.
15. If a decision is taken to apply the policy, the Council will write to inform the individual that:
1. the decision has been taken
2. what it means for their contacts with the Council
3. what restrictions will be put in place and how long these will last; and
4. what the individual can do to appeal the decision.
5. enclose a copy of this policy with the letter.

What happened

16. This section sets out the key events in this case and is not intended to be a full chronology.
17. The Council completed a care act assessment of Ms X’s care and support needs in March 2024. The assessment included 5 hours per week of domiciliary support, and that Ms X should be referred to the Council’s Independent Living Service (ILS) for home adaptations to be considered. The Council did not make a referral at that time.
18. The Council referred Ms X to its ILS in October 2024 for it to assess her bathroom and decide whether any adaptations were needed. Ms X called the Council in early April 2025 to chase progress. Her case with ILS was moved from “referral” to “allocation” as a result of this contact.
19. Ms X called the Council again in early April 2025 to say she felt she required a review of her care as her needs had increased.
20. Ms X made a formal complaint to the Council in mid-April. This complaint included her concerns about delays in reviewing her care needs and in making adaptations to her bathroom. She said the latter had been ongoing for six to 12 months.
21. Two members of the ILS team visited Ms X at home in late April to assess her bathroom needs.
22. Council officer A called Ms X at the end of April to discuss her recent contacts with the Council, and agreed that her care plan needed to be reviewed.
23. Council officer B called Ms X in early May. The officer said they would arrange for the Council to carry out a review of Ms X’s care and support needs. In the interim, the officer reinstated the care package of five hours per week of support that had been in place in 2024, based on the March 2024 assessment (Ms X had previously cancelled this package). That care re-started in early June, before Ms X cancelled it again in late July. The reasons for the cancellation are the subject of a data protection complaint that is not part of this investigation.
24. The Council responded to Ms X’s complaint at stage 1 of its complaints process in mid-May. It apologised for the delay in moving Ms X’s case with ILS from referral to allocation but noted that the assessment had now taken place. It advised Ms X to liaise directly with the ILS staff who had carried out the assessment, regarding the viable options for bathroom adaptations. The response also said that a referral had been passed to the social care team for them to “assess accordingly”. The letter explained how she could escalate her complaint to stage 2 if she was dissatisfied.
25. Also in mid-May, Council officer C wrote to Ms X. This letter said that Council staff had felt the need to contact emergency services due to concerns about Ms X’s welfare during several calls with her in recent weeks. And so, in order to “alleviate any unintended escalation or potential distress when needing to make contact with the Council”, the letter asked “that if you need to contact the Council about any matter, you initially contact the allocated team”. The allocated team was the West Mental Health Duty Team (WMHDT). The letter concluded “they will be able to speak to you about the matter and support you in resolving it, contacting other Council departments if required. I hope the above assists you in accessing the correct support as and when needed.”
26. Ms X emailed the WMHDT on 15 May to express her frustration that, having been directed to contact that team, she was unable to do so. She had called the duty line ten times that day without success. She said this was causing her distress and hindering her ability to access the support she needed. Council officer B responded, saying that Ms X was welcome to contact her directly in the interests of consistency, support and familiarity, or she could contact the WMHDT if she preferred. The Council also treated this contact as a second stage 1 complaint to which it sent a formal response on 29 May.
27. Ms X told the Ombudsman she made a stage 2 complaint (that is, a request to escalate her original complaint of mid- April) by email on 27 May. The existence of an email of that date is logged in the social care rolling record, but the Council did not provide it to the Ombudsman and said it was not a stage 2 escalation of her mid-April complaint. The Council did not provide a stage 2 response to Ms X’s original complaint.
28. The Council’s formal response of 29 May to Ms X’s complaint of 15 May said that Council officer C’s letter had been professional and appropriate in tone. It said it had “clearly outline[d] the correct processes and procedures in place to support residents”. The letter said it hoped that the earlier response from Council officer B had “helped to address your concerns regarding your specified contact route and demonstrates the supportive nature of the arrangement”. The letter did not state whether Ms X was able to contact other services if necessary.
29. A member of the ILS team wrote to Ms X in early June suggesting specific bathroom adaptations. Ms X did not respond to this because, following the Council’s letter of 15 May, she believed she was barred from contacting the Council other than via the WMHDT.
30. In mid-June Council officer D emailed Ms X to agree a date and time to carry out the CAA review. She offered dates within the following two weeks. Ms X emailed the Council on the same day, 11 June asking:
1. Why she had received no acknowledgement of, or response to, her stage 2 complaint of 27 May, including about her request for a Care Act review;
2. Whether Council officer D was qualified to conduct a CAA; and
3. How she could contact the Council when the WMHDT, to which she had been directed, did not answer her repeated calls.
31. Ms X sent another long email to the Council on 21 June, again asking it to respond to her stage 2 complaint of 27 May.
32. Council officer B responded to this email in late June. They explained:
1. The Customer Rights team had advised her that Ms X’s complaint had been “concluded”;
2. Council officer D’s role included completing CAAs and reviews; and
3. The reasons why the WMHDT’s single duty worker might not always be able to answer the phone when Ms X called (they may be attending a meeting, an urgent home visit, or attending to another call or communication channel).

They also reiterated that their intention in naming themself as a specific point of contact for Ms X whilst she was waiting to be allocated a social worker was to provide consistency and support. They apologised that may have felt like a barrier to Ms X’s access to the service.

33. Ms X established that Council officer D had previously worked for the local mental health Trust. She telephoned Council officer B to request that her review be re-allocated to someone who had not previously worked for that organisation.
34. The review was allocated to Council officer E on 26 June. On 30 June, they made an initial visit to Ms X’s home to begin gathering information for the review.
35. Ms X approached the Ombudsman in early July 2025.
36. In mid-July Council officer B had a telephone conversation with Ms X during which Ms X complained that she was not allowed to contact her allocated social worker (Council officer E). Council officer B explained that was not the case, and that she was also free to contact the voting service, occupational therapy and the planning department as necessary (all services that Ms X considered she had been prevented from contacting). Ms X said she would need a new letter from the team that sent her the letter of 15 May before she could believe that. Council officer B asked the Customer Experience team to write to Ms X to clarify which departments and people she could speak to.
37. In early August, a member of the Council’s legal team wrote to Ms X. That letter included: “For the avoidance of doubt, you are currently formally permitted to contact (and to be in ongoing contact with) other departments directly where you feel comfortable to do so, and the process of contacting your worker in the first instance has been done, as outlined, as a supportive measure”.
38. The CAA was completed in mid-August, and included a personal budget for 25 hours per week of care and support. The resulting CSP was dated early October. That did not include an agreed package of care because Ms X is working with Council officer E to decide whether she would like to meet her care needs by employing a personal assistant using a direct payment.
39. A member of the ILS team emailed Ms X in late September to discuss bathroom adaptations. Ms X responded briefly in early October to explain that she unable to reply in full (because she believed was barred from doing so).
40. The Customer Rights team wrote to Ms X in late November, saying that the letter of 15 May had been “an informal agreement to help make communication with the Council easier for [her]”. It clarified that: “You can still speak to other professionals too, including your Occupational Therapist (OT) and the team surrounding them. This set up is to provide you with a clear explanation of what is available to you, not explicit rules for you to be bound by. You can contact any professional/team working with you in any order that works for you.”
41. Ms X immediately contacted the ILS team to confirm that she would like to discuss potential bathroom adaptations. The ILS team responded in mid-February 2026.

My findings

Delay in carrying out a Care Act review

42. Ms X’s previous CSP had been completed in March 2024. She requested a review of this in April 2025. In mid-June, the Council allocated an officer to carry out the review. As set out at paragraph 10, councils should review plans at least every 12 months. The delay of three months between March and mid-June 2025 was fault, that caused Ms X uncertainty.
43. Delays that occurred in completing the review between mid-June and early October were not fault. The evidence shows that Council officer E made regular contact with Ms X during this period and built a constructive working relationship with her to facilitate the review. Ms X confirmed to me that delays during this time were intentional: they had been agreed with her to reduce additional stress during a period in which her physical health challenges were acute.
44. The delays throughout 2025 did not cause a loss of care provision as Ms X has chosen not to access the care and support budgeted for in the assessment until she is well enough to arrange to employ a personal assistant using a direct payment.

Unfair contact restrictions

45. Ms X complained that the Council had barred her from contacting, and therefore accessing, several Council services between May and November 2025. Ms X said the restrictions the Council had put on her were the same as those included in the Unreasonable Behaviour Policy (that is, contact was restricted to an individual named officer or team) but without the Council naming that policy or giving her a route of appeal.
46. The Council, in response to our enquiries, said it did not implement its Unreasonable Behaviour Policy in Ms X’s case, and I have seen no evidence that it did so. The letter the Council sent to Ms X on 15 May did not include any of the elements it would have needed to in order to implement that policy. I find the contact arrangements were intended to be supportive rather than restrictive. The letter did not place restrictions on Ms X’s ability to contact teams other than the WMHDT. It was not the Council’s fault that Ms X interpreted it in that way.
47. It follows that it was not the Council’s fault that Ms X did not contact services other than the WMHDT following receipt of the letter of 15 May. However, once Ms X told the Council that she believed it was preventing her from contacting other services, the Council should have made it clear to her that this was not the case. The Council missed the opportunity to clear up Ms X’s misunderstanding in its letter of 29 May. That was fault, that caused Ms X confusion and frustration.
48. Another opportunity to clarify matters arose in mid-July. Council officer B correctly explained to Ms X that it was open to her to contact other Council services. This was not fault. When Ms X insisted that she needed to hear this from the team (Customer Experience) that had written the 15 May letter, and Council officer B agreed to facilitate this, that letter should have been sent sooner than late November. The delay of four months between July and November was fault. However, that delay did not cause Ms X further injustice because the Council’s legal team wrote to her in early August. That letter made it clear that Ms X was not subject to formal restrictions on her contact with the Council. And, as it was authored by the Council’s legal team, it was clearly the Council’s corporate position.

Delay in carrying out bathroom adaptations

49. The needs assessment of March 2024 said that Ms X should be referred to the ILS for bathroom adaptations to be considered. The Council did not make the referral until seven months later, in October 2024. That delay was fault.
50. Ms X’s case was not allocated for assessment until she complained in April 2025, a further delay of six months. The delay was fault.
51. The Council assessed the adaptations Ms X needed in April 2025 and contacted her in early June to discuss these in more detail. As set out above, it was not the Council’s fault that Ms X believed she was barred from speaking to the ILS team. And so, the delay between early June and late November, when the Customer Rights team wrote to Ms X to clarify lines of communication, was not the Council’s fault. The further delay of three months between late November 2025 and the ILS team contacting Ms X in mid-February 2026 was fault.
52. The faults I have identified caused Ms X injustice in the form of uncertainty and confusion, and a cumulative delay of 16 months in having her bathroom adapted to her assessed needs.

Failure to respond to complaint of 27 May 2025

53. The Council told me that Ms X did not escalate her original complaint of mid-April to stage 2 of its complaints process. I have seen evidence that Ms X submitted a stage 2 complaint by email on 27 May. The Council said this did not relate to her April complaint, but rather to her separate complaint about contact restrictions. As the Council has not provided me with a copy of this email, I cannot say whether it was at fault for not escalating Mrs X’s stage 1 complaint of mid-April to stage 2 at that time. However, Ms X also sent emails to the Council on 11 and 21 June that set out clearly her wish to pursue the CAA aspect of her complaint. The Council did not respond to this aspect of her complaints, which was fault. This fault caused Ms X injustice in that she felt forced to escalate her complaints to the Ombudsman in the absence of a stage 2 response, causing her time and trouble.

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Action

54. Within one month of my final decision, the Council will:
1. Apologise to Ms X for the injustice caused by the faults I have identified through my investigation;
2. Make Ms X a symbolic payment of £100 to acknowledge the frustration, confusion and uncertainty caused by its faults, and £400 for the impact of the delay in assessing her for appropriate bathroom facilities; and
3. Confirm with Ms X what action she needs to take to ensure the bathroom adaptations progress.
55. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended.
56. The Council should provide us with evidence it has complied with the above actions.

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Decision

57. I find fault causing injustice. The Council has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman